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APPLICATION FOR PERMIT 32 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 L!Z- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '" (Complete in Triplicate) C l.J k Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thition is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules anS�� I "tof 91�h oaquin Local Health District. > �Vl VICES �ERSJ11�/5ER Job AddresscZ D 1 -k City Lot Size PM Owner's Name L��J ddress 1 r Phone 3 3 Contractor '^►�`�`�""'" 1'4Address 4 C -""`� �._ License N i;��?� Phone ? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 11 Tracy Type of Casing Specifications 1"1 Public i n Other Ll Delta Depth of Grout Seal Type of Grout _ I4rigation Approx. Rept l I Eastern surface Seal Installed by Repair Work Done; ❑ Type of Pump hJl H.P. � - ! State Work Done Well Destruction t ❑ Well Diameter Sealing Material Stop 50'1 3 Depth Filler Material (Below 561 TYPE OF SEPTIC WORK: NEW INSTALLATION.I'I REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is �3 .- ------available-within.200-feet.)-- Installation will serve_ Residence Commercial Other Number of living units: Number of bedrooms e Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments /J�} PKG. TREATMENT PLT. CI ( q` Method of Disposal " ,f Distance to nearest: Well Foundation Property Line � f LEACHING LINE R, ❑ No. & Length of lines Total length/,size FILTER BED � ,' ❑ Distance to nearest: WellFoundation f Property Line l: x SEEPAGE PITS r I 1 Depth Size i Number SUMPS € 0 Distance to nearest: Well Foundation Property Line DISPOSAL POND5',1 ❑ I hereby certify that I have prepared this application and that the work will be done 11n.accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this perrnit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for all required inspections. Complete drawing on reverse side. i �, rr Signed X_ _ s""'Title: Date: s FOR{DEPARTMENT USE ONLY Application Accepted by Date ��ry�-2 Area Pit or Grout Inspection by Date f=inal Inspection by Date Additional Comments: Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED 13Y DATE PERMWNO. r.EH 13.24(REV.r/e 51 1/1 EH 1426